Admission and Consultation Rules

The following guidelines for specific medical disorders are intended to expedite care of ED patients. They have been reviewed and agreed upon by all Departments and Divisions that provide consultation to the Adult ED.

Admission Decisions

The ED Attending will determine the need for admission for all ED patients (AED, RME, PED) with input from consulting services

The ED Attending will determine appropriateness for OBS/CORE with input from UR

The ED attending has admitting privileges to all inpatient services; for cases with no specific guidelines, the ED Attending will use their best professional judgment in determining the admitting service

The ED Attending should document the rationale for admission, admitting service, and required level of care

A collaborative discussion should be had with the admitting service

After discussion with the admitting service, the ED provider will place the admission order which transfers care to the admitting service (unless there is a medical emergency)

If an admitting service attending feels the patient would be best cared for on another inpatient service, the admitting attending should speak to the attending of that service and a final decision should be accomplished and reported back to the ED attending within 30 minutes; if this does not occur, escalate to the associate/CMO who will make the decision

If there is disagreement about a admitting service, the ADMITTING ATTENDING NEEDS TO CALL THE ALTERNATE/MORE APPROPRIATE ADMITTING SERVICE ATTENDING

If the admitting service has not evaluated the patient and placed orders within 2 hours of the admission, the ED should place abbreviated admission orders ("holding orders" - activity, vitals, oxygen, IV)

Patients <18 will be admitted to Pediatrics; ages 18-20 will be admitted to Pediatrics at the discretion and capacity of the Peds service

Complicating Medical Conditions (CMC)

One or more potentially active acute medical conditions that the non-IM/FM service does not usually manage AND is likely to require ongoing management or active monitoring during the hospitalization; the decision of what constitutes a CMC is made by the ED Attending

Any discussion for most appropriate admitting service given a CMC will occur at the attending level (inpatient service & ED); elevation to division chief/department chair, then associate/CMO (Dr. Stein/Dr. Mahajan); chief residents cannot replace an attending for this discussion

Service specific, so it might vary by services

Consideration: Simply having stable co-morbidities that require continuation of home medications and therapies does NOT constitute a reason to deviate from the admission guidelines

Consideration: Significant co-morbidities that separately would require admission to a medicine service, consider admitting that patient to medicine with the surgical or specialty service on consult

If there is disagreement about a CMC, the ADMITTING ATTENDING NEEDS TO CALL THE ED ATTENDING

Residents cannot overrule admission decisions made by the ED attending

Residents cannot discharge a patient from the ED who has been admitted to their service without an explicit discussion and agreement from their attending

Assisting services for specific CMCs

Primary surgical admission requiring ICU care will have a consult to trauma/surgical critical care in the surgical ICU

C-team can be consulted for CHF as a complicating medical condition

Nephrology can be consulted to assist with HTN as a complicating medical condition

Geriatrics may be consulted 24/7 and is available to assist in the care of patients greater than 65 years old (will go as low as 60 for ortho patients)

Endocrine: may be consulted to assist with blood sugar management

Nephrology: may be consulted to assist with blood pressure control; if the patient needs cardiac clearance as well, cardiology can perform this function and help manage hypertension

Pre-operative Clearance: If >65, consult geriatrics; otherwise, third-call can assist in providing this service

Breast Diagnostic Center (BDC) performs same day/next business day. If patient is going to BDC on the same day, save the patient's ED bed to return to after the procedure.

ED provider orders both “US Breast R/L” and “US Drainage Abscess or Cyst," as future order, for next business day or date/time discussed w/ BDC over the phone. Place in clinical info in “relevant history: location what o’clock and r/o abscess.” Do not need to fax form.

ED provider initiates PO antibiotics.

During 7a-330p: contact BDC to add on case x68244

Afterhours: Next business day follow up 830a in BDC in B200

Applies to DHS or MHLA or OOP

Once seen in BDC – gets auto-f/u with Breast Surgery Clinic

Consider eConsult to Specialty Breast Services:

if palpable mass persists after 14-21 days, ultrasound and needle biopsy should be performed of solid components by radiology department

Any patient with burns and concomitant trauma (such as fractures) in which the burn injury poses the greatest risk of morbidity or mortality. In such cases, if the trauma poses the greater immediate risk, the patient may be initially stabilized in a trauma center before being transferred to a burn unit. Physician judgment will be necessary in such situations and should be in concert with the regional medical control plan and triage protocols

Burned children in hospitals without qualified personnel or equipment for the care of children

Burn injury in patients who will require special social, emotional, or rehabilitative intervention.

NSTEMI

C-team: if appears to be secondary to ACS or CHF

IM/FM: if appears to be secondary to non-cardiovascular cause (eg, sepsis)

Trauma: if appears to be secondary to a traumatic injury (eg, cardiac contusion after a motor vehicle accident) and NOT the etiology of the trauma (eg, cardiac syncope leading to a motor vehicle accident)

Determination of the most likely cause of the NSTEMI will be made by the ED Attending

For patients with massive PE or who are rapidly deteriorating due to known or suspected PE where thrombolytics are felt to be indicated emergently by the Attending Emergency Physician, do not delay administration in order to obtain consultation

If the patient is admitted, make reasonable attempts to include the admitting team in any decision about emergent thrombolytics